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psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - to expect busy clinicians to
mechanistically review all their medication orders, and then to change cognitive
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psnet.ahrq.gov/web-mm/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
April 27, 2022 - Patient Safety Challenges of this Case RCFEs commonly care for older residents with cognitive impairment
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - Although cognitive function and coordination might be impaired, ventilatory and cardiovascular functions … 21 While it may seem intuitive that checklists designed to prevent patient safety lapses and reduce cognitive
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psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
August 01, 2018 - interfaces, some VR simulators now have the capacity to promote the acquisition of a full range of cognitive … We are interested in using cognitive engineering methods to really get at what people are thinking when
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psnet.ahrq.gov/node/50842/psn-pdf
January 29, 2020 - Patient Identification Errors: A Systems Challenge
January 29, 2020
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
The Cases
The following four events involving five patients all involved…
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psnet.ahrq.gov/node/33845/psn-pdf
November 01, 2017 - In Conversation With… Wanda Pratt, PhD
November 1, 2017
In Conversation With… Wanda Pratt, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
Editor's note: Wanda Pratt is a Professor in the Information School with an adjunct appointment in the
Division of Biomedical and …
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psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
January 01, 2024 - often the product of a series of errors (both human and technical), and why it is important to mitigate cognitive
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psnet.ahrq.gov/node/61082/psn-pdf
July 23, 2020 - of loneliness are a critical risk factor for negative health outcomes, and are
directly linked to cognitive
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psnet.ahrq.gov/node/49633/psn-pdf
September 01, 2011 - Moreover, the majority of nursing home residents experience dementia or other cognitive impairments (
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psnet.ahrq.gov/web-mm/unfamiliar-catheter
November 01, 2006 - The user's physical, perceptual, and cognitive abilities; the clinical environment; interactions with
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psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - words, why are sound-alike drugs stored in close proximity and why haven't steps
been taken to reduce cognitive
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psnet.ahrq.gov/node/73526/psn-pdf
July 28, 2021 - study by Flynn et al.4
In a geographically diverse sample that included 429 community pharmacies, cognitive
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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - Antibiotic and Opioid Stewardship in Dentistry
December 7, 2020
Cognitive
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
January 01, 2024 - especially in patients who may not be able to communicate effectively with the nursing staff due to cognitive
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psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - Unplanned weight loss, increased incontinence and decreased cognitive function
has also been reported
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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - – Psychotherapies may include supportive, cognitive, and dialectical behavioral therapies, but
their
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psnet.ahrq.gov/web-mm/discharging-our-responsibility
January 16, 2019 - August 20, 2018
Cognitive bias impact on management of postoperative complications, medical
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Transfusion Overload
November 1, 2012
WebM&M Cases
Cognitive
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - Basic assumptions and lessons distilled from the cognitive systems engineering literature (11-14) are
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psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - to safely use prescribed medications, as they are disproportionately affected by
limited literacy, cognitive